Historical Medical Policies and Clinical UM Guidelines
Historical Medical Policies
Medical policies contained within this page are historical and not the most current versions. Current medical policy content may be accessed from the Medical Policies and Clinical Utilization Management (UM) Guidelines page.
Implementation dates of the most current versions vary per state notification requirements.
- DME.00025 Self-Operated Spinal Unloading Devices
- SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting
- SURG.00121 Transcatheter Heart Valve Procedures
- SURG.00165 Histotripsy
Historical Clinical UM Guidelines
Clinical UM guidelines contained within this page are historical and not the most current versions. Current clinical UM guideline content may be accessed from the Medical Policies and Clinical Utilization Management (UM) Guidelines page.
Implementation dates of the most current versions vary per state notification requirements.
- CG-DME-16 Pressure Reducing Support Surfaces – Groups 1, 2 & 3
- CG-DME-31 Powered Wheeled Mobility Devices
- CG-DME-41 Ultraviolet Light Therapy Delivery Devices for Home Use
- CG-LAB-11 Screening for Vitamin D Deficiency in Average Risk Individuals
- CG-MED-39 Bone Mineral Density Testing Measurement
- CG-MED-51 Three-Dimensional (3-D) Rendering of Imaging Studies
- CG-MED-56 Non-Obstetrical Transvaginal Ultrasonography
- CG-MED-69 Inhaled Nitric Oxide
- CG-SURG-61 Cryosurgical or Radiofrequency Ablation to Treat Solid Tumors Outside the Liver
- CG-SURG-79 Implantable Infusion Pumps
- CG-SURG-95 Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention
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